AUDIT OF THE COVERAGE DECISION MAKING PROCESS IN A GOVERNMENT AGENCY IN URUGUAY: FROM THE GUIDELINES TO PATIENTS

GARCIA MARTÍ, SEBASTIAN; PICHON-RIVIERE A,; ARUJ, PATRICIA; GLUJOVSKY, D; BARDACH, ARIEL; RODRIGUEZ, A

Conferencia; Ispor 4th Latin America Conference; 2013

OBJECTIVES: The National Resources Fund (FNR) is a government agency devoted to provide coverage of high cost technologies in Uruguay. A particular characteristic of the FNR is being involved in the whole process of providing access to these technologies, from its buying to its patient administration. To guide this process the FNR, has some clinical coverage guidelines that are used in the clinical coverage decision with each individual patient. During 2009 and 2012 the FNR did an audit process of these guidelines and asked IECS (a non profit academic organization) from Argentina to implement it. To present the process were 12 of these guidelines were audited (colorectal, kidney, CNS and breast cancer, leukemias, cystic fibrosis, hepatitis C, diabetes, palivizumab and rituximab, rheumatoid arthritis and multiple mieloma) and the coverage decision taken on patients with the corresponding diseases. METHODS: Systematic bibliographic searches were performed to audit the guidelines and the clinical record of patients with the corresponding diseases was audited summarizing 200 patients in total. RESULTS: Regarding the guidelines it was observed that in general there were adequate in its clinical content and updated with the actual evidence promoting a better clinical decision coverage process. Only some reporting aspects as date of bibliographic searches not reported or not clear specification of authors or methodology followed were mentioned. Regarding the patients audit, in 198 cases the decision was in concordance with the guideline being adequate in almost all the cases. CONCLUSIONS: An audit process of the coverage decisions implemented in a government agency by an external organism as the one described in this study allows to identify potential improvements to the process, promotes transparency and at the end a better coverage decision making process and utilization of health resources.